Provider Demographics
NPI:1023583515
Name:MELAITAU, TEBEI LORENZO
Entity type:Individual
Prefix:
First Name:TEBEI
Middle Name:LORENZO
Last Name:MELAITAU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-5000
Mailing Address - Country:US
Mailing Address - Phone:323-409-4314
Mailing Address - Fax:
Practice Address - Street 1:7636 OWENSMOUTH AVE APT 20
Practice Address - Street 2:
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91304-4810
Practice Address - Country:US
Practice Address - Phone:626-213-9965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-10
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA033480616101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty